For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.   Case: An elderly widow who just lost her spouse.  Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:  • Metformin 500mg BID  • Januvia 100mg daily  • Losartan 100mg daily  • HCTZ 25mg daily  • Sertraline 100mg daily  Current weight: 88 kg Current height: 64 inches Temp: 98.6 degrees F BP: 132/86  By Day 3 of Week 7 Post a response to each of the following: • List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.  • Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.  • Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.  • List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.  • List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.  • For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities? • Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.  Respond to the these discussions. All questions need to be addressed. Discussion 2 Me Treatment of a Patient with Insomnia                   The case presented this week, is that of a 75-year-old widow who just lost her spouse 10-months ago. Th patient presents with chief complaints of insomnia. Past medical history of DM, HTN, and MDD is reported. Since the passing of her husband, she states her depression has gotten worse .

1. For this Discussion, review the case Learning Resources and the
case study excerpt presented. Reflect on the case study excerpt
and consider the therapy approaches you might take to assess,
diagnose, and treat the patient’s health needs.
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today
with chief complaint of insomnia. Patient is 75 YO with PMH of
DM, HTN, and MDD. Her husband of 41 years passed away 10
months ago. Since then, she states her depression has gotten
worse as well as her sleep habits. The patient has no previous
history of depression prior to her husband’s death. She is
awake, alert, and oriented x3. Patient normally sees PCP once
or twice a year. Patient denies any suicidal ideations. Patient
arrived at the office today by private vehicle. Patient currently
takes the following medications:
•
Metformin 500mg BID
•
Januvia 100mg daily
•
Losartan 100mg daily
•
HCTZ 25mg daily
•
Sertraline 100mg daily

2. Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
By Day 3 of Week 7
Post
a response to each of the following:
• List three questions you might ask the patient if she were in
your office. Provide a rationale for why you might ask these
questions.
• Identify people in the patient’s life you would need to speak to
or get feedback from to further assess the patient’s situation.
Include specific questions you might ask these people and why.
• Explain what, if any, physical exams, and diagnostic tests
would be appropriate for the patient and how the results would
be used.
• List a differential diagnosis for the patient. Identify the one
that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be
appropriate for the patient’s antidepressant therapy based on
pharmacokinetics and pharmacodynamics. From a mechanism of
action perspective, provide a rationale for why you might
choose one agent over the other.
• For the drug therapy you select, identify any contraindications
to use or alterations in dosing that may need to be considered

3. based on the client’s ethnicity. Discuss why the
contraindication/alteration you identify exists. That is, what
would be problematic with the use of this drug in individuals of
other ethnicities?
• Include any “check points” (i.e., follow-up data at Week 4, 8,
12, etc.), and indicate any therapeutic changes that you might
make based on possible outcomes that may happen given your
treatment options chosen.
Respond to the these discussions. All questions need to be
addressed.
Discussion 2 Me
Treatment of a Patient with Insomnia
The case presented this week, is that of a 75-year-old
widow who just lost her spouse 10-months ago. Th patient
presents with chief complaints of insomnia. Past medical history
of DM, HTN, and MDD is reported. Since the passing of her
husband, she states her depression has gotten worse as well as
her sleep habits. The patient has no previous history of
depression prior to her husband’s death. She is awake, alert, and
oriented x3. Patient normally sees PCP once or twice a year.
Patient denies any suicidal ideations. Patient arrived at the
office today by private vehicle. Patient currently takes the
following medications: Metformin 500mg BID, Januvia 100mg
daily, Losartan 100mg daily, HCTZ 25mg daily, and Sertraline
100mg daily. Current weight: 88 kg. Current height: 64 inches.
Temp: 98.6 degrees F. BP: 132/86 (Walden University).
Question number one, what brings you in today? By
asking an open-ended question, the patient is more willing to

4. share information with the provider (Stern, 2016). Another
question that would be of beneficial knowledge during the
interview is, do you consume caffeine? If so, how much caffeine
do you consume in a day? Caffeine consumption close to
bedtime contributes greatly to insomnia (Farazdaq et al., 2018).
Lastly, the third question that should be asked is, do you suffer
from Gastro Esophageal Reflux Disease (GERD). According to
Farazdaq, Andrades, and Nanji, (2018) GERD is a contributing
factor to insomnia in elderly patients. By asking the above
questions, the provider can rule out environmental factors while
assessing the patients concerns with open-ended questions.
People in the patient’s life that could provide further
information is children or caretakers. Questions that would be
appropriate to ask the patient’s children or caretaker would be if
there is a recent decrease in her appetite, energy, mood, or
interests. By asking about these areas of the patient’s life will
provide external information that the patient might be
withholding or may be unaware of.
Insomnia relies heavily on self-report for a diagnosis (Levenson
et al., 2015). Also, a physical exam could be performed with the
order of blood testing to rule out thyroid problems. According
to Dr. Abhinav Singh (2021), hyperthyroidism results in
nervousness from overactivity of this hormone, and insomnia is
often a symptom. Administering the Hamilton Anxiety Rating
Scale (HAM-A) would assess the severity of the patient’s
anxiety. The HAM-A results would aid with further treatment of
the patient’s insomnia, if related to anxiety (Psychiatry &
Behavioral Health Learning Network, 2021). Another
appropriate scale to administer to this patient is the Hamilton
Depression Rating Scale (HDRS). HDRS is an assessment that
focuses on feelings of guilt, mood, suicidal ideation, activities,
weight, various stages of insomnia, and many more important
areas (Hamilton, 1960).

5. The patient presents with a previous diagnosis of
depression. The differential diagnosis for this patient is
Generalized Anxiety Disorder (GAD), secondary to husband’s
death. There are many possible changes within the living
dynamics, such as financial burdens, fear of her own death, and
suddenly sleeping alone. Changes within this patient’s routine
may be a cause of reported insomnia.
Temazepam is FDA approved for insomnia, and used
off-label for anxiety disorders, acute mania, psychosis, and
catatonia (Puzantian & Carlat, 2020). Temazepam is generally
effective in the treatment of insomnia, by enhancing widespread
inhibitory activity of GABA (Levenson et al., 2015).
Temazepam is metabolized through the liver without CYP450
(Puzantian & Carlat, 2020). Another good sleep aid choice is
Trazodone. Trazodone is widely used for insomnia (Levenson et
al., 2015). Trazodone is FDA approved for the treatment of
major depression and used off-label for insomnia and anxiety
(Puzantian & Carlat, 2020). Trazodone inhibits serotonin
reuptake, alpha-1 adrenergic receptor antagonist, and serotonin
5-HT2A and 5-HT2C receptor antagonist (Puzantian & Carlat,
2020). And Trazodone is metabolized primarily through
CYP3A4 to active metabolite mCPP, that is metabolized by
2D6, inducing P-glycoprotein (Puzantian & Carlat, 2020).
Trazodone, however, carries the side effect of daytime
somnolence and dizziness (Puzantian & Carlat, 2020).
The favorable medication for this patient, is
Temazepam. Temazepam is a safer medication to use in elderly
patients because of the lack of active metabolites, its short half-
life and absence of drug interactions (Puzantian & Carlat,
2020). The patient is currently taking Metformin, Januvia,
Losartan, HCTZ, and Sertraline. Based on the current
medications, the patient is being treated for diabetes mellitus,
hypertension, and depression. Adding Temazepam to the
patient’s medication regimen would not result in toxicity of

6. other medications. Sleep is heritable and regulated by numerous
genes. A genome wide association study found numerous single-
nucleotide polymorphisms (SNPs) significantly associated with
insomnia symptoms. The most significant SNPs occurred within
genes involved in neuroplasticity, stress reactivity neuronal
excitability, and mental health (Rajib, 2020).
The starting dose of Temazepam is lower in the elderly
population (Puzantian & Carlat, 2020). The proper dose to begin
with this patient, is Temazepam 7.5mg tab PO QHS. At the 4-
week checkup, the expected outcome would be an increased
ability to sleep, and reduced anxiety. If these results have not
been achieved, Temazepam 15mg tab PO Q HS would be
ordered. Temazepam does have the risk of weakness and
dizziness, so great care and caution would need to be taken
when increasing the dose. There needs to be an evaluation of
the effects at week 8, or sooner if needed. The maximum dose
of Temazepam is 30mg PO Q HS, and even lower in the elderly
(Puzantian & Carlat, 2020).
References
Farazdaq, H., Andrades, M., & Nanji, K. (2018, December 31).
Insomnia and its correlates among elderly patients presenting to
family medicine clinics at an academic center
. Malaysian family physician: the official journal of the
Academy of Family Physicians of Malaysia.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382090/.
Hamilton, M. (1960). Hamilton Rating Scale for Depression.
PsycTESTS Dataset
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, 56–62. https://doi.org/10.1037/t04100-000
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The

7. Pathophysiology of Insomnia.
Chest
,
147
(4), 1179–1192. https://doi.org/10.1378/chest.14-1617
Puzantian, T., & Carlat, D. J. (2020).
Medication fact book for psychiatric practice
. Carlat Publishing, LLC.
Rajib, D. (2020). Do genes matter in sleep? -A comprehensive
update.
Journal of Neuroscience and Neurological Disorders
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4
(1), 014–023. https://doi.org/10.29328/journal.jnnd.1001029
Singh, A. (2021, March 8).
Could Your Thyroid be Causing Sleep Problems?
Sleep Foundation. https://www.sleepfoundation.org/physical-
health/thyroid-issues-and-sleep.
Stern, T. A. (2016).
Massachusetts General Hospital: psychopharmacology and
neurotherapeutics
(1st ed.). Elsevier.
Walden University. (n.d.).
Treatment for a Patient with a Common Condition
.
https://class.content.laureate.net/14884e77402afe219224c67c4f
0463b3.html.